Healthcare Provider Details

I. General information

NPI: 1063307304
Provider Name (Legal Business Name): MAKAYLA EVANGELINE DENNISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 STANDIFORD AVE STE 3
MODESTO CA
95350-0736
US

IV. Provider business mailing address

3144 G ST STE 125-208
MERCED CA
95340-1300
US

V. Phone/Fax

Practice location:
  • Phone: 209-947-0494
  • Fax: 209-364-1060
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: